THE ALLIANCE FOR INTERNATIONAL MEDICAL ACTION ALIMA Susan

THE ALLIANCE FOR INTERNATIONAL MEDICAL ACTION ALIMA Susan Shepherd & Matt Cleary

WHO ARE WE? ALIMA is an independent medical NGO founded in 2009 Ø (1990) Medical Activities: Paediatrics with Malnutrition, –Core PPFounded in France in 2009 by a team of former Médecins Sans Surgery, Maternal Child Health, Hospitalisation, General Frières/Doctors Without Borders senior executives, ALIMA, the Medicine Alliance for International Medical Action, is an independent medical NGON (1999) is headquartered in Dakar, Senegal, with –ALIMA Projets pilotes (2000). additional administrative offices in Paris & New York Þ Des innovations par des scientifiques utilisés essentiellement par des ex Sud Soudan 1998, Angola 2002) à faible échelle compte tenu des limites techniques. 1500 Employees 2016: 32 Million Euro Budget

THREE PRINCIPAL AREAS OF ACTION / EXPERTISE Provides medical care in humanitarian crises Supports the development of national medical organizations Conducts operational research to bring medical innovation to the field

OUR ACTIVITY In 2015 we treated: • • • 607, 000 consultations 42, 000 hospitalisations 1, 500 surgical interventions That Includes: • 92, 000 severely malnourished children • 308, 000 malaria cases • 50, 000 ANC consultation • 9, 000 deliveries • 50, 000 MUAC Mothers • 129, 000 children in SMC

ALIMA HISTORICAL GROWTH 2009 - 2016 30 25 20 15 10 5 0 2009 2010 2011 2012 No. of Projects 2013 No. of Countries 2014 2015 2016

WHERE WE WORK Current Emergency Missions: • Tanzania • Cameroon • Guniea (Ebola) Planned opening 2016: • Nigeria

Port au Prince, Haiti: Su. Tra 2 Study • ALIMA • Université de Lille • Centre National de la Recherche Scientifique Delauche MC, Blackwell N, Le Perff H, et al. A Prospective Study of the Outcome of Patients with Limb Trauma following the Haitian Earthquake in 2010 at One- and Two- Year (The Su. Tra 2 Study). PLo. S Currents. 2013; 5: ecurrents.

ALIMA’S COMMITMENT TO OPERATIONAL RESEARCH • 6 Peer-reviewed publications – Traumatology (1) – Paediatrics and Malnutrition (3) – Ebola (2) • More in submission – Paediatrics and Malnutrition (3) – Ebola (1) • Current Partnerships – University of Copenhagen: Treat. FOOD – INSERM and NIH: JIKI and Prevail – Malaria Research & Training Centre, Univ of Bamako – Epicentre: 1000 Days

CURRENT RESEARCH PROJECTS – FOCUS ON PREVENTION MUAC-only (BF) - Simplifying treatment of SAM CPS + LNS (Mali) - Simultaneous prevention of Malaria and Malnutrition 1000 Days (Niger) - maternal-infant care package Di. MAS (Chad) - Automated PCR infectious causes of diarrhoea in malnourished

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ALIMA: MALARIA & MALNUTRITION Countries today where we confront Malaria & Malnutrition co-morbidity in our projects: • • • Niger Mali Burkina Faso Cameroon DRC Planned 2016 • Nigeria Our approach: • Treatment – Community programs – Hospitalisation • Prevention – SMC: sulfadoxine-pyrimethamine plus amodiaquine – Mosquito net distribution – Supplementary Feeding – 1000 Days (Niger) • Clinical Research/Delivery Science – – Treatfood MUAC Mothers MUAC Only 1000 Days (Niger)

OVERLAP IN MALARIA AND MALNUTRITION Niger 2015 • 34. 5% (13, 084/37, 916) of ‘uncomplicated’ SAM children in 2 projects were malaria RDT(+) • 46% of children with severe malaria were SAM in-patients (2, 485/5, 402)

SEASONAL MALARIA CHEMOPREVENTION (SMC): POTENTIAL TO IMPACT SAM INCIDENCE IN BURKINA FASO BOUSSE, Burkina Faso 2013 2014 % reduction from 2013 to 2014 Total nb SAM admitted to project 1188 816 31, 31% Total nb SAM admitted to hospital 270 101 62, 59% Total nb pediatric hosp admissions 674 356 47, 18% Total nb of transfusions 327 126 61, 47% July to December SMC for 32, 756 children 3 -59 m Aug-Nov 2014

LNS – DATA SUGGESTING INFLUENCE ON MALARIA MORTALITY From: Effect of Preventive Supplementation With Ready-to-Use Therapeutic Food on the Nutritional Status, Mortality, and Morbidity of Children Aged 6 to 60 Months in Niger: A Cluster Randomized Trial. JAMA. 2009; 301(3): 277 -285. doi: 10. 1001/jama. 2008. 1018

1000 DAYS PACKAGE OF CARE - ~4, 000 children 6 -23 m enrolled in Niger

MALARIA-MALNUTRITION-MEASLES: DRC 2015 Epicenter of 2015 Measles epidemic • • 153, 258 children 6 m – 10 y vaccinated against measles 6, 313 children treated for malaria 3. 416 children treated for measles < 500 children treated for acute malnutrition

L’importance de l’ionogramme Documentation de troubles ioniques CRENI Mirriah • 73 enfants admis août-oct 2015 • Test selon avis du médecin • Age moyen = 18. 6 mois • 28% d’enfants avec hyponatrémie sévère (Na < 125 mmol/L) • 87% décès – hypokaliémie profonde • Délai moyen entre admission et test = 2 j (mode = 1 j, range 1 -10 j) The Alliance for International Medical Action

OPERATIONAL ISSUES RELATED TO MALARIA AND MALNUTRITION PREVENTION IN THE SAHEL • Cost: – approx. 4 Euro per child per season (1 € drug cost, 3 € distribution cost): How to reduce – It is possible to make the CPS more efficient but also more efficient by combining distribution of anti-malarial drugs to other medical activities as screening for malnutrition, immunization catch-up, the distribution of vitamin A, deworming; or – Reduce the number of distributions to once or bi-monthly: requires greater community participation • • Cost of SQ-LNS: approximately US$ 3. 00/month Accessibility of Amodiaquine: – Limited number of Company pre-qualified for production. – Supply is less than demand, – Taste of drug

RESEARCH / OPERATIONAL QUESTIONS RELATED TO SMC 1. Study the impact of combined SMC & LNS distributions on rates of Malaria, febrile illness and acute malnutrition and potentially stunting 2. Drug resistance related to SMC activity 3. Are antimalarial pharmacokinetics altered with LNS co-administration? 4. How to achieve the best SMC distribution planning a. b. c. d. Effectiveness Community participation Timing Cost

RESEARCH / OPERATIONAL QUESTIONS RELATED TO MALNUTRITION & MALARIA PREVENTION 1. Increasing incidence of malaria morbidity and mortality in Eastern DRC? 2. Role for malaria vaccine trial? 3. Advantages to associating LNS with malaria vaccine trial?